PROTOCOLS regarding EMERGENCY OBSTETRIC CARE AND NEWBORN CARE
Baghdad, Iraq
January 2013
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Table of Contents
Acronyms ............................................................................................................................................................. 3
PROTOCOLS ON EMERGENCY OBSTETRIC CARE ......................................................................................... 4
Preface ................................................................................................................................................................. 4
How to use these protocols................................................................................................................................. 4
Pre-eclampsia and Eclampsia .............................................................................................................................. 6
Prolonged Labor ................................................................................................................................................ 10
PostPartum Hemorrhage ................................................................................................................................... 12
Acknowledgment............................................................................................................................................... 16
PROTOCOLS ON EMERGENCY NEWBORN CARE .............................................................................................. 17
Preface ............................................................................................................................................................... 17
How to use these protocols............................................................................................................................... 17
Birth asphyxia .................................................................................................................................................... 19
Advanced resuscitation for birth asphyxia ........................................................................................................ 23
Management of hypothermia ........................................................................................................................... 26
Management of Neonatal Sepsis ...................................................................................................................... 29
Management of Neonatal Convulsions ............................................................................................................. 31
Management of Jaundice .................................................................................................................................. 33
Acknowledgments ............................................................................................................................................. 35
2
Acronyms
MSAF
Meconium stained amniotic fluid
PHC
Primary Health Care
PHCC
Primary Health Care Center
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PROTOCOLS ON EMERGENCY OBSTETRIC CARE
Preface
Maternal mortality remains a problem in Iraq. Most maternal deaths are caused by complications during pregnancy and childbirth such as bleeding, high blood pressure, infection
and prolonged labor. Many of these deaths can be prevented by skilled birth attendants by
early recognition of problems and initiation of treatment and referral when indicated. As part
of its commitment to working with the MOH Iraq the PHCPI, has developed and is improving standards of care for the management of common obstetric emergencies at the Primary
Health Care Centers (PHCCs).
These protocols have been developed for use in emergency obstetric care at PHCs. They
were adapted from the following guidelines for emergency obstetric care: 1) WHO/UNFPA/UNICEF/World Bank reference “Managing Complications in Pregnancy and Childbirth:
A guide for midwives and doctors” and 2) protocols developed by the Government of Tamil
Nadu’s Directorate of Reproductive & Child Health with support from the UNICEF India
Chennai Field Office. Interventions described in these protocols are based on the latest
available scientific evidence and are applicable to PHCs in Iraq. These protocols should be
updated as new information emerges. It is hoped that these protocols will be used in all
PHCs whenever an obstetric care provider is confronted with an obstetric emergency. It is
also hoped that these guidelines will be the standard for assessing quality of emergency
obstetric care at the PHCs.
How to use these protocols
These obstetric protocols cover the immediate management of common life threatening
obstetric emergencies seen at the PHCs, and are designed as job aids for trained health
workers.
Each protocol has four major headings. The user starts at the top with “Suspect” and goes
down the chart through “Assess”, “Classify” and “Treat”. “Suspect” reminds the user of
the symptoms and signs that should alert her/him to the obstetric emergency. “Assess” refers to the symptoms and signs which help the user to “Classify”. “Treat” refers to the specific management of the problem. In addition, some protocols have boxes such as “Key
Points” or “Special Note”. These provide additional useful and important information.
The technical basis for each protocol is discussed in this chart booklet. Technical papers
provide evidence for the management of the obstetric emergencies.
As the first step in the implementation of these protocols at each PHC, the Clinic Manager
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in charge of the PHC center should discuss these protocols with his/her medical and nursing and other paramedic colleagues in the PHC center. During these discussions, the team
should identify differences between existing practices in the PHC center with those recommended in these protocols, and use the technical papers to understand the rationale for the
recommendation. If training is required concerning specific skills (e.g., aortic compression)
or in the use of specific drugs (e.g., magnesium sulfate use in eclampsia), the PHC clinic
manager or district level manager should make arrangements for the required training. The
team could use simulated clinical practice to familiarize themselves with the protocols. The
PHC clinic manager or district level manager and his/her team should also ensure that all
drugs listed in these protocols are available at the PHC center at all times.
The individual protocols (wall charts) should be displayed in the labor/delivery room and in
all other areas in the facility where obstetric emergencies are managed. Each protocol will
serve as a guide for staff involved in emergency obstetric care. As a quality assurance/ improvement exercise, the quality of care provided concerning obstetric emergencies at the
PHC center should be audited/ reviewed by the staff using these protocols as the standard.
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Pre-eclampsia and Eclampsia
Hypertension complicates 5 to 10% of all pregnancies and is associated with 13% of all maternal deaths. Hypertension in pregnancy is defined as systolic blood pressure of 140 mm
Hg or greater and/or diastolic blood pressure of 90 mm Hg or greater. Hypertension diagnosed for the first time after 20 weeks of pregnancy is referred to as pregnancy-induced hypertension; a pregnant woman with hypertension diagnosed before 20 weeks is said to
have chronic hypertension.
Diastolic blood pressure is a good indicator of prognosis for the management of hypertension in pregnancy as it measures peripheral resistance and does not vary with the
woman’s emotional state to the degree that systolic pressure does. Diastolic blood pressure
is recorded/noted at the point at which arterial sounds disappear. This protocol uses only
diastolic blood pressure measurements for the classification and management of hypertension in pregnancy. Diastolic blood pressure measurements between 90-109 mm Hg are
considered mild hypertension while measurements above these levels are considered severe hypertension.
Pre-eclampsia is pregnancy induced hypertension with proteinuria. Eclampsia is the occurrence of convulsions in a pregnant woman with hypertension in pregnancy. Since eclampsia is the most common reason for convulsions in pregnant women, and since it is associated with significant maternal and perinatal morbidity and mortality, it is recommended that
any pregnant woman with convulsions should be considered and managed as eclampsia
unless there is sufficient information to consider another cause for convulsions.
The etiology of pre-eclampsia and its prevention are not clear. Both the mother and the fetus may be affected by pre-eclampsia depending on the severity of the condition and the
age of onset of disease. The mother may suffer from the adverse effects of high blood pressure (convulsions, cerebral hemorrhage, cardiac and renal failure) while the baby may suffer from inadequate placental blood flow (fetal growth restriction, fetal distress and fetal
death). The only definitive treatment for pre-eclampsia is delivery of the baby.
This results in rapid and almost complete resolution of symptoms and signs. Making a decision regarding delivery is dependent on many factors, in particular the maturity of the baby,
the condition of the mother, and the facilities available for maternal and neonatal care. In
severe pre-eclampsia and eclampsia, the risks to the mother’s health are sufficiently high to
warrant delivery of the baby irrespective of its maturity. However, in cases of mild hypertension in pregnancy when the baby is not mature, there is a place for expectant management
of pregnancy. If the diastolic pressure is 105 mm Hg or more, give antihypertensive drugs.
The goal is to keep the diastolic pressure between 90 mm Hg and 100 mm Hg to prevent
cerebral hemorrhage. Hydralazine is the drug of choice.
 Give hydralazine 5 mg IV slowly every 5 minutes until blood pressure is lowered. Repeat hourly as needed or give hydralazine 12.5 mg IM every 2 hours as needed.
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 If hydralazine is not available, give:
-labetolol 10 mg IV
 If response is inadequate, (diastolic B/P remains above 105 mm Hg) after 10
minutes, give labetolol 20 mg IV
 Increase the dose to 40 mg and then 80 mg if satisfactory response is not obtained after 10 minutes of each dose
-OR nifedipine 5 mg under the tongue:
 If response is inadequate (diastolic B/P remains more than 105 mm Hg after
10 minutes, give an additional 5 mg under the tongue.
NOTE: There is concern regarding a possibility of an interaction with magnesium sulfate
that can lead to hypotension. Use of beta-blockers is associated with fetal growth restriction
while use of nifedipine for mild hypertension is associated with worsening of pre-eclampsia.
Consider delivery if the baby is mature, or if there is increasing proteinuria or if hypertension
is not adequately controlled with antihypertensive medication. Sedatives, tranquilizers and
diuretics have no role in the management of mild hypertension in pregnancy.
A woman with severe pre-eclampsia or eclampsia should be delivered as soon as possible.
Magnesium sulfate is the drug of choice for prevention and treatment of convulsions.
Magnesium sulfate is superior to lytic cocktail, diazepam and phenytoin. The loading dose
is 4 grams administered intravenously as a 20% solution over 5 minutes followed immediately by 10 grams of a 50% solution given intramuscularly (5 grams in each buttock with 1
cc of 2% lignocaine in the same syringe). If convulsions recur more than 15 min after administration of the loading dose, an additional dose of 2 g should be given intravenously
over 5 minutes. To prevent further seizures, maintenance doses of 5 g are given intramuscularly every 4 h until 24 hr have elapsed after delivery or last convulsion whichever occurred last. Since magnesium depresses neuromuscular transmission, monitor the woman
for respiratory depression (rate should be more than 16/min) and deep tendon reflexes (the
knee jerk should be elicitable fore the next dose is given). Also, since magnesium is excreted through the kidney, decreased urine output can be associated with magnesium toxicity. Ensure that urine output is at least 30 ml/hr over the preceding 4 hrs before giving further doses of magnesium sulfate. If knee jerks are not elicited, or if the urine output is less
than 30 ml/hr over 4 hours, or if respiratory rate is less than 16/minute withhold the next
dose until these have returned to normal.
POSTPARTUM CARE for women with pre-eclampia or eclampsia
•
•
Anticonvulsive therapy should be maintained for 24 hours after delivery or the last
convulsion, whichever occurs last.
Continue antihypertensive therapy as long as the diastolic pressure is more than 105
mm Hg (diastolic).
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•
•
•
Continue to monitor urine output.
Nifedipine and beta-blockers may be used in the postpartum period.
Follow up after discharge and reduce/stop treatment as appropriate.
A woman with convulsions should be protected from injury. Gently hold her to prevent her
from hurting herself. Introduction of a mouth gag may cause injury and is best avoided.
Maintain adequate intravenous hydration. Plan delivery after initiating anticonvulsant and
antihypertensive treatment.
References
Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild
to moderate hypertension during pregnancy (Cochrane Review). In: The Cochrane Library,
Issue 1, 2002. Oxford: Update Software.
De Swiet M, Tan, LK The management of postpartum hypertension. British Journal of Obstetrics & Gynaecology 109: 733-736, 2002.
Duley L, Gulmezoglu AM Magnesium sulphate versus lytic cocktail for eclampsia (Cochrane
Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update Software.
Duley L, Henderson-Smart D Magnesium sulphate versus diazepam for eclampsia
(Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update Software.
Duley L, Henderson-Smart D Magnesium sulphate versus phenytoin for eclampsia
(Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update Software.
Duley L, Henderson-Smart DJ Drugs for rapid treatment of very high blood pressure during
Pregnancy (Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford: Update
Software.
The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies,
Benefit from magnesium sulphate? The Magpie trial: a randomized placebo controlled trial.
Lancet 359: 1877-1890, 2002.
WHO/UNFPA/UNICEF/World Bank “Managing Complications in Pregnancy and Childbirth:
A
Guide for midwives and doctors “ WHO/RHR/00.7 2000.
8
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Prolonged Labor
Prolonged labor is an important cause of maternal and perinatal ill health and death.
Prolonged labor and the associated problems can be prevented by close monitoring of
events in labor, recording progress of labor on a partograph and intervening when the
partograph shows evidence of slow labor.
The partograph is a graphic representation of events in labor. In its simplest form, it records
cervical dilatation and descent of the head against time. After 4 cm dilatation, the cervix dilates normally at a minimum rate of 1 cm/hr.
Prolonged labor may result from obstruction to the passage of the fetus through the
birth canal or for other reasons. Obstructed labor is more common if the baby is very
large or there is a fetal malpresentation. When labor is obstructed, the woman is usually
distressed with pain and is dehydrated, and the lower part of the uterus may be
stretched. The head may feel jammed in the pelvis with overlapping of the fetal skull
bones. Untreated obstructed labor can result in uterine rupture and even genital fistula.
Hence if labor is obstructed, the woman should be delivered as quickly as possible.
Non-obstructed prolonged labor is more common than obstructed prolonged labor.
Slow progress of labor without obstruction is usually because of inefficient uterine contractionsIf
Slow labor is demonstrated on the partograph, uterine contractions should be strengthened
by amniotomy, in the first place, followed by oxytocin infusion. If progress is unsatisfactory
Even after ensuring adequate uterine contractions (3 contractions in 10 minutes lasting
more than 40 seconds), she should be delivered by caesarean section.
Slow progress may also result from fetal malpresentations. Here the presenting part may
be large and not fit adequately in the pelvis. Clinical examination can identify slow progress
due to malpresentations. In some malpresentations (e.g. face), oxytocin may be used to
strengthen uterine contractions. In other malpresentations (e.g. brow-unless the baby is
very small) caesarean section is the preferred treatment.
Disproportion between the size of the fetal head and the maternal pelvis (cephalopelvic
disproportion) is a diagnosis made after excluding poor uterine contractions and
malpresentations.
Reference:
WHO/UNFPA/UNICEF/World Bank “Managing Complications in Pregnancy and Childbirth:
A guide for midwives and doctors” WHO/RHR/00.7 2000.
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PostPartum Hemorrhage
Bleeding following Childbirth (Postpartum Hemorrhage)
Bleeding during pregnancy and childbirth accounts for 25% of all maternal deaths. Severe
blood loss is more common following birth of the baby. After the placenta separates, the
contractions of the uterus occlude the blood vessels supplying the placenta preventing excessive blood loss. Failure of the uterus to contract (atonic uterus) is the commonest cause
of bleeding after childbirth. Other causes for postpartum hemorrhage include lacerations of
the genital tract, retention of placental fragments and uterine infections.
Atonic postpartum hemorrhage may follow any delivery. There is no reliable predictor for
this condition. It is therefore essential to ensure that measures are taken in all women to
ensure that the uterus contracts after childbirth. Active management of the third stage of labor (the stage when the placenta is expelled) has been shown to reduce postpartum hemorrhage in over 60% of women. Active management includes the administration of an oxytocic drug soon after the baby is born and before the placenta is expelled, delivery of the
placenta by controlled cord traction, and uterine massage to ensure that it is contracted. It
is important to carefully monitor the mother for bleeding, especially in the first two hours after childbirth.
Interventions to stop bleeding should be taken immediately should bleeding become excessive. These interventions may include uterine massage to ensure contractions, administration of therapeutic oxytocics, and other measures (bimanual uterine compression, aortic
compression) to reduce blood loss. If the woman is bleeding and the placenta is retained, it
should be removed manually. Genital lacerations may occur following spontaneous childbirth but are more often seen following instrumental delivery. Here bleeding occurs even
when the uterus is contracted. Prompt visualization of the lacerations and repair are required to control bleeding. Occasionally the uterus may rupture during delivery. Bleeding
may occur through the vagina or into the abdomen. Surgical intervention should be carried
out as soon as the woman’s hemodynamic condition is stabilized.
Inversion of the uterus is a rare complication of childbirth and may present with shock and
bleeding. Prompt repositioning of the uterus and correction of shock should be undertaken.
Oxytocics
Oxytocin, ergometrine, and misoprostol have been used in the active management of third
stage. Unlike oxytocin, ergometrine is associated with increase in blood pressure, nausea
and vomiting. Ergometrine is best avoided in women with hypertension or heart disease.
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Further, ergometrine preparations in tropical storage conditions deteriorate faster than oxytocin preparations. Hence the preferred oxytocic for routine active management of third
stage of labor in all cases is an intramuscular injection of 10 units of oxytocin.
However ergometrine may be used as intramuscular or intravenous injections of 0.2 mg in
the treatment of postpartum hemorrhage (maximum 5 doses at 15 min intervals). Similarly
larger doses of oxytocin (20 units in 1 L of saline) are infused rapidly in the treatment of
postpartum hemorrhage (however, not more than 3 Liters of fluids containing oxytocin
should be infused in 24 hours). Following is a table showing drugs that can be used for
uterine atony.
DRUG
DOSE &
ROUTE
CONT.
DOSE
MAX
DOSE
CONTRAINDICATION
IM 10 U OR
IV 20u in 1000ml at
40 drops /min
Not > 40
U infused
at rate of
0.02-0.04
U/min.
No IV push
IM OR IV Slowly 0.2
mg
Repeat 0.2mg after
15 mins, if required, and every
four hours
Five
doses
(Total 1.0
mg)
High BP
MISOPROSTOL
200 mcg Oral +
None
1000 mcg
Asthma
(CYTOTEC)
400 mcg Sublingual
OXYTOCIN
IV 20 U in 1000 ml
NS at
>60drops/min
ERGOMETRINE
Heart Disease
Heart Disease
OR
1000 mcg rectal
PROSTAGLANDIN
IM only
0.25mg
Total 8
Asthma
F2a
0.25mg
Every 15
Doses
Heart Disease
Minutes
=2 mg
References
AbouZahr C. Antepartum and postpartum hemorrhage In: Murray CJL, Lopez AD,
editor(s). Health dimensions of sex and reproduction. Boston: Harvard University Press,
1998:165-190.
Prendiville WJ, Elbourne D, McDonald S Active versus expectant management in the
third stage of labor (Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Oxford:
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Update Software.
Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third
Stage of Labor (AMTSL): A Reference Manual for Health Care Providers, Prevention of
Postpartum Hemorrhage Initiative (POPPHI), 2007.
World Health Organization. Stability of injectable oxytocics in tropical climates: Results
of field surveys and simulation studies on ergometrine, methylergometrine, and oxytocin.
WHO: Geneva, 1993.
WHO/UNFPA/UNICEF/World Bank “Managing Complications in Pregnancy and
Childbirth: A guide for midwives and doctors” WHO/RHR/00.7 2000.
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Acknowledgment
“These protocols on Emergency Obstetric Care have been adapted from the WHO/UNFPA/UNICEF/World Bank Manual, “Managing Complications in Pregnancy and Childbirth: A
Guide for Midwives and Doctors”.
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PROTOCOLS ON EMERGENCY NEWBORN CARE
Preface
Neonatal mortality contributes to two thirds of infant mortality and remains unacceptably
high in Iraq. Two-thirds of neonatal deaths occur during the first week of life. Most of these
deaths can be prevented by early identification, initiation of effective treatment and referral
when indicated. Highly sophisticated medical care is not essential to save the majority of
these newborn babies. With early identification, initiation of effective treatment and referral
when indicated, these deaths can be largely prevented.
Protocols have been developed to provide standards of care for the management of common neonatal emergencies that can be implemented at PHCs with limited resources. The
management guidelines in these protocols are consistent with other WHO/UNFPA/UNICEF/World Bank material. They are based on the latest available scientific evidence and it is planned to update them as new information is acquired.
It is expected that these guidelines will be followed by doctors, nurses, midwives and others
involved in newborn care at PHC centers.
How to use these protocols
These neonatal protocols outline the management of commonly encountered emergencies
seen at the first referral level, and are designed to help the nurse and doctor to recognize
and treat these problems appropriately.
Each protocol has three major headings. The user starts at the top with “Problem” and
goes down the chart through “Findings” and “Management”. “Problem” refers to the common presenting symptoms that should alert the user to the neonatal emergency. “Findings”
refer to the signs that help the user to identify the underlying problem and “Management”
refers to the specific treatment modalities for the problem. In addition, some protocols have
boxes labeled “Special situations” which contain some additional useful and important information.
The technical basis for each protocol is discussed in this chart booklet. Technical papers
provide evidence for management of the neonatal emergencies.
As a first step in the implementation of these protocols at each first referral unit, the PHC
Clinic manager in charge of the center should discuss these protocols with his/her medical
and nursing colleagues in the center. During these discussions, the team should identify
17
differences between existing practices in the facility with those recommended in these protocols, and use the technical papers to understand the rationale for the recommendation. If
training is required in the use of a particular skill (e.g., neonatal resuscitation), the PHC
Clinic manager or District Manager should make arrangements for the required training.
The team could use clinical drills/simulated practice to familiarize themselves with the protocols. The Clinic Manager and his/her team should also ensure that all drugs listed in these
protocols are available in the center at all times.
The individual protocols (wall charts) should be displayed in the labor/delivery room, and in
any other areas in the PHC center where neonatal emergencies are likely to be seen. Each
protocol will serve as a ready reference for staff involved in emergency neonatal care.
As a quality assurance/improvement exercise, the quality of care in neonatal emergencies
at the PHC center and first referral unit should be audited by the team using these protocols
as the standard.
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Birth asphyxia
Birth asphyxia remains a major cause of neonatal morbidity and mortality despite advances
in antepartum and intrapartum monitoring techniques developed over the last 3 decades.
According to WHO estimates, 3% of approximately 120 million infants born every year in
developed countries suffer birth asphyxia requiring resuscitation, of whom 900,000 die
each year. Although prompt resuscitation after delivery can prevent many of these deaths
and disabilities, it is often not initiated or the procedures used are inadequate or wrong.
Failure to initiate and sustain breathing at birth would result in birth asphyxia. In most
circumstances, it is impossible to grade the severity of asphyxia by clinical methods at
birth. It should be stressed that resuscitation be started immediately in all babies who are
apnoeic or have only gasping/irregular respiration.
BASIC RESUSCITATION
Regardless of the cause of birth asphyxia and its severity, the primary aim of management
is to ensure oxygenation and initiate spontaneous breathing. In most instances this can
be achieved by following the initial steps of resuscitation, which constitute basic
resuscitation. It is imperative that all health care providers associated with newborn care
be competent in performing basic resuscitation.
Anticipation, adequate preparation, timely recognition and prompt and appropriate action
are critical for success of basic resuscitation. It must be emphasized that universal precautions should be a part of all resuscitative efforts.
The need for resuscitation cannot be anticipated in approximately 50% of all resuscitated
infants. Therefore one must be prepared to resuscitate at all deliveries. Every birth
attendant should be trained in resuscitation and the presence of resuscitation equipment
in proper working order should be verified before every delivery.
EQUIPMENT NEEDED
BASIC RESUSCITATION
Self-inflating bag (Newborn size)
Face mask (No. 0 and 1)
Mucus extractor/Suction apparatus
Small towel for positioning
Source of warmth (radiant heat
or lamp)
Oxygen (if available),
Clean exam gloves
2 clean, dry blankets
(preferably cotton flannel), or towels
ADDITIONS FOR ADVANCED RESUSCITATION
Laryngoscope with straight blade (No. 0& 1)
Endotracheal tube (Size 2.5, 3, 3.5 & 4 mm.ID)
NG tubes No. 6 & 8, Syringes 1ml, 2ml, 10ml
(Disposable)
Needles No 23 & 24
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Stethoscope
Clock with second hand
Adhesive tape
Drugs- epinephrine(1:10,000),
Naloxone, normal saline
If a newborn does not cry or breathe or is gasping within 30 seconds of birth, the essential
steps of basic resuscitation should be initiated immediately. The important steps in basic
resuscitation are prevention of heat loss, opening of airway and positive pressure
ventilation
Prevention of heat loss in newborn is vital because hypothermia increases oxygen consumption and impedes effective resuscitation. Every newborn should be immediately
placed on a clean, dry cloth on the maternal abdomen and dried. Breathing should be assessed while drying. Drying provides sufficient stimulus for breathing and no further stimulation is usually necessary.
If the baby is breathing, the wet cloth should be removed, the baby should be placed skinto-skin on the mother’s chest, and covered with a clean, dry cloth including the head (use a
hat, if available). If the baby is not breathing or is gasping, the wet cloth should be removed,
the baby wrapped in a clean, dry cloth and the head covered, preferably with a hat. Still on
the mother’s abdomen, the airway should be cleared with gentle suctioning, first the mouth
and then the nose, and stimulation provided by rubbing with the heel of the hand up and
down along the baby’s spine. If the baby is still not breathing, oxytocin should be given to
the mother, the cord clamped and cut, and the baby moved to a firm, warm, flat, clean and
dry surface for ventilation.
The newborn must be positioned on his/her back with the neck slightly extended. Using a
small rolled under the newborn’s shoulders can help attain the correct position.
Positive pressure ventilation is the most important step of newborn resuscitation for
ensuring adequate ventilation of the lungs, for initiation of spontaneous breathing and
perfusion of vital organs like brain, heart and kidneys.
Ventilation can always be performed using a bag and mask in room air; oxygen may be
used if available. Use a self-inflating ventilation bag with an automatic pop-off at 40 cm H2O
pressure. Assisted ventilation rate should be at a rate of 40/minute. The face mask should
be applied on the face so as to cover the nose, mouth and chin to obtain a good seal. Use a
size 1 mask for a normal weight newborn and a size 0 mask for a low birth weight newborn
(less than 2500 grams). Adequacy of ventilation is assessed by observing chest movements. These are the essential first steps of basic newborn resuscitation. With basic newborn resuscitation, more than three-fourths of the cases of birth asphyxia will establish
spontaneous breathing.
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Check for breathing after 1 minute of ventilation (40 breaths). If the baby is breathing at a
rate of at least 30/minute, stop ventilation and observe baby for 5 minutes. If breathing regularly without difficulty, place the baby skin-to-skin on the mother’s chest, cover including
the head, and encourage early initiation of breast feeding (within one hour of birth). After
first breastfeeding, proceed with other routine essential newborn care.
If baby is still not breathing after one minute of ventilation, is gasping, or is breathing less
than 30 breaths/minute, call for help and check heart rate. If heart rate is >100/minute, resume ventilating at 40 breaths/minute as before. If heart rate is <100/minute, suction again,
reposition, check to make there is a good seal when the mask is reapplied, and squeeze
the bag harder. Continue ventilating at 40 breaths/minute. If continued ventilation is necessary, check for breathing every 1 minute and check heart rate. Discontinue ventilation when
baby is breathing at 30 breaths per minute or more on his own.
If there is no breathing or heart rate after 10 minutes, discontinue ventilation and explain to
the mother and family that resuscitation has not been successful and the baby has died.
Provide emotional support. If there is a heart rate after 10 minutes but no breathing, continue ventilating at 40 breaths/minute until transport by ambulance to a hospital with newborn intensive care unit and advanced newborn resuscitation is possible. (Note that this is
management exclusive to Iraq related to culturally accepted norms.)
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Advanced resuscitation for birth asphyxia
A small proportion of infants fail to respond to basic resuscitation with bag and mask. In this
situation, additional decisions must be made and appropriate action taken. These
additional steps constitute advanced resuscitation. Advanced resuscitation can only be
practiced in healthcare centers where (a) trained staff with the necessary equipment and
supplies are available; (b) at least two skilled persons are available to carry out the
resuscitation; (c) there are sufficient deliveries for the skill to be maintained; and (d) the
center has the capacity to care for or to transfer newborns who suffer severe birth asphyxia
since they are expected to have problems after being resuscitated.
Endotracheal intubation
Endotracheal intubation is a complicated procedure that requires good training and is useful
for prolonged ventilation and will not be available at the PHC level. It is indicated in resuscitating a baby with diaphragmatic hernia and tracheal suctioning of depressed babies born
through meconium stained amniotic fluid.
(Note: endotracheal suctioning of vigorous infants with MSAF does not improve outcome
and may cause complications.) The presence of meconium stained amniotic fluid without
other signs of asphyxia does not require endotracheal suctioning. It does not improve outcome and may even cause complications.
Chest Compression
Chest compressions are not recommended for basic resuscitation. Bradycardia is usually
caused by lack of oxygen, and in most situations the heart rate will improve once effective
ventilation is established.
However, in newborns with persistent bradycardia (HR<80 and falling) despite adequate
ventilation, chest compression may be life saving by ensuring adequate circulation. Two
people are needed for effective ventilation and chest compression. Studies have shown
better results with chest compression given with the hands encircling the chest compared to
the two-finger method. Before the decision to give chest compression is made, heart rate
must be assessed correctly.
Drugs
Drugs are rarely indicated in resuscitation of the newly born infant and will not be administered at the PHC level. Administer epinephrine if, despite adequate ventilation with 100%
oxygen and chest compressions, the heart rate remains< 80bpm. Volume expansion and
23
blood transfusion are recommended in situations of hypovolemia. Sodium bicarbonate is
not recommended in resuscitation of neonates and may in fact be potentially hazardous.
Cleaning and Disinfection of Equipment
Equipment and supplies must be cleaned and disinfected after each use. The face mask
and Penguin suction device should be placed in 0.5% chlorine solution for 10 minutes for
decontamination, then washed with soapy water and rinsed with clean water. The mask can
then be reused. The Penguin is made of silicone and can be boiled for 20 minutes or autoclaved. If the mask is also made of silicone, it can be high level disinfected by boiling for 20
minutes or by autoclaving. The ventilation bag should be wiped off with 0.5% chlorine,
washed off with soapy water, and then rinsed with clean water. It can then be reused. DO
NOT SUBMERGE THE VENTILATION BAG IN DECONTAMINATION SOLUTION or autoclave unless the ventilation bag is made by Laerdal with instructions that this is
permissible.
References
1. Helping Babies Breathe, American Academy of Pediatrics, 2010.
2. Essential newborn care. 1996 WHO/FRH/MSM/96.13.
3. Basic Newborn Resuscitation: a practical guide WHO/RHT/MSM/98.1.
4. Tyson JE. Immediate care of the newborn infant. In: Sinclair JC, Bracken MB (eds).
Effective care of the newborn infant. Oxford, Oxford University Press, 1992, 21-31.
5. Niermeyer S, Kattwinkel J, Reempts PV et al. International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care: International Consensus on Science. Pediatrics
2000:106(3); p. e 29.
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Management of hypothermia
The fetus develops in a thermally protected environment. At birth, the wet and naked infant
is dependent on his caregivers for maintenance of body temperature. A term newborn infant, by and large, maintains a constant deep body temperature over a narrow range of environmental temperature. However, in preterm babies the body temperature fluctuates with
changes in environmental temperature. Thus thermal management of the newborn is the
cornerstone of neonatology and hypothermia is an important cause of morbidity and mortality especially in developing countries. Modes of heat loss from the baby to the environment
are conduction, convection, radiation and evaporation.
Measurement of Temperature
The ideal technique for measuring temperature is a rapid, painless and reproducible
method that accurately reflects core body temperature. Axillary temperature is as good as
rectal and probably safer. A glass thermometer is placed in the roof of axilla with the infant’s upper arm held tightly against the chest wall and the temperature is recorded after 3
minutes (or until it beeps if using a digital thermometer).
Definitions based on axillary temperature:



Cold stress 36°-36.4°C
Moderate hypothermia 32° - 35.9°C
Severe hypothermia <32°C
Prevention of hypothermia
Close the delivery room doors and windows. Turn off fans/air conditioners before delivery.
Dry the newborn immediately after birth, remove the wet cloth, place skin-to-skin on the
mother’s chest and cover with a clean, dry, warm cloth including the head. Use a hat, if
available. If immediate skin-to-skin is not possible (e.g. baby delivered by C/section), dry
the baby immediately, remove the wet cloth, and wrap baby including the head. Use a hat,
if available. Use additional radiant heat, if available for the baby who cannot be placed skinto-skin with the mother. Delay bathing for at least 6 hours, preferably 24 hours.
REFERENCES
1. Thermal Protection of the Newborn. WHO/RHT/MSM/97.2.
2. Hypothermia in Newborn. In: NNF Teaching Aids on Newborn Care, 2nd Edition. Deorari
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AK, editor. Delhi, Winmedicare. 1998: 9-15.
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Management of Neonatal Sepsis
Neonatal sepsis continues to be the commonest cause of neonatal mortality accounting
for more than 50% of all neonatal deaths. Newborn babies can acquire infection from the
mother that usually presents in the first 72 hours of life (early onset sepsis), or from the
surrounding environment that presents beyond 72 hours (late onset sepsis). Infection in
newborn babies whether pneumonia, septicemia or meningitis, all present with similar
clinical features. If facilities are available, one must obtain a blood culture and perform a
lumbar puncture, which would help the clinician arrive at a precise diagnosis and optimize
management. However, it must be kept in mind that treatment is to be started immediately
even before a specific diagnosis can be established.
The course of the illness may be fulminant and lead to death rapidly. Therefore it is very
important that septic newborns be recognized by the health care provider and referred
immediately to a hospital, if needed. If immediate referral is not possible,
management at community health level with administration of parenteral antibiotics and
provision of supportive care has been shown to reduce mortality considerably. In addition
a sick septic baby in a health care facility may also require IV fluids, oxygen administration
and blood transfusion.
The common bacteria seen in neonatal sepsis include gram-positive organisms like
streptococci and staphylococci, and gram-negative pathogens such as E.coli, Klebsiella
and Enterobacter. Combination therapy with ampicillin and gentamicin would cover most
of these organisms. When infection with Staphylococcus is suspected (pustules, umbilical
cord infection, etc.), ampicillin may be substituted with cloxacillin. The total duration of
therapy should be at least 10-14 days (21 days in case of meningitis).
REFERENCES
1. Essential newborn care. 1996 WHO/FRH/MSM/96.13
2. “Management of Newborn Problems: A Guide for Doctors, Nurses, and Midwives” a
WHO publication of the Integrated Management of Pregnancy and Childbirth (IMPAC)
series - in press.
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Management of Neonatal Convulsions
The immature brain is particularly susceptible to convulsions that are more common in
the newborn period than at any other time of life. Convulsions occur in 6-13% of very low
birth weight infants and in 1-3/1000 term babies. In developing countries, common causes
of neonatal convulsions include perinatal asphyxia, infections, metabolic disorders like
hypoglycemia and intracranial hemorrhage. Early recognition and prompt treatment are
vital, as delayed recognition of a treatable cause can have a significant impact on the
child’s future neurological development.
The usual well organized tonic-clonic seizures seen in older children and adults are not
a feature in neonates because of the immaturity of the newborn brain. Subtle seizures
constitute 50% of seizure activity in newborns. These seizures manifest as jerking of the
eyes, repeated blinking, fluttering of the eyelids, drooling, sucking, yawning and recurrent
apnoeic spells. They may also manifest as complex, purposeless movements like
swimming or bicycling. Other forms of convulsions include clonic, tonic and myoclonic
seizures. One should make an attempt to determine the possible cause of convulsion from
the history and physical findings. It is important to differentiate convulsions from spasms of
neonatal tetanus as specific therapy is needed to treat neonatal tetanus. Simple investigative
facilities like blood sugar estimation should be done to rule out treatable causes such as hypoglycemia.
The mainstay in the control of seizures is anticonvulsants of which phenytoin is the preferred drug. Diazepam is best avoided in treatment of neonatal convulsions because of its
many adverse effects in this age group.
REFERENCES
1. Voipe JJ. Neonatal seizures. In. Neurology of the Newborn. 4th ed. Philadelphia,
W.B. Saunders company. 2001:178-216.
2. Rennie JM. Seizures in the newborn. In RennieJM, Roberton NRC, editors. Textbook
of Neonatology, 3rd edition. Edinburgh, Churchill Livingstone. 1999;1213-1222.
3. Kuban KCK, Filiano J. Neonatal Seizures. In. Cloherty JP, Stark AR, editors. Manual
of neonatal care 4th edition. Philadelphia, Lippincott-Raven. 1998:493-504.
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Management of Jaundice
Many babies may have jaundice in the first week of life, especially small babies weighing
<2500 grams or born before 37 weeks of gestation. In most babies however, the level of bilirubin that causes jaundice is not harmful and does not require treatment. In the majority of
these cases, jaundice appears after the first 24 hours of life and disappears by the end of
the first week. In a few babies, jaundice levels may rise critically and cause significant damage to the central nervous system. PHC personnel involved in newborn care should be able
to recognize babies with significant jaundice and refer for treatment promptly with the goal
of prevention of bilirubin encephalopathy.
The severity of jaundice can be reliably assessed by blanching the skin over different parts
of the body. Those babies with moderate to severe jaundice can be effectively treated with
intensive phototherapy and adequate hydration. A very small subset of these babies would
need exchange transfusion.
Any jaundice during the first 24 hours of life or severe jaundice in the early neonatal age is
usually hemolytic in nature. Hemolytic jaundice in a newborn baby is most commonly
caused by Rh factor or ABO blood group incompatibility between the baby and the mother,
or G6PD deficiency in the baby.
Phototherapy is the most widely used treatment for jaundice and it is both safe and effective. It acts by converting bilirubin into photoproducts that are more soluble than bilirubin.
REFERENCS
1. “Management of Newborn Problems: A Guide for Doctors, Nurses, and Midwives” a
WHO publication of the Integrated Management of Pregnancy and Childbirth (IMPAC)
series - in press.
2. Provisional committee for quality improvement and subcommittee on hyperbilirubinemia.
American Academy of Pediatrics. Management of Hyperbilirubinemia in the healthy term
newborn. Pediatrics 1994: 94; 558-65.
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Acknowledgments
These protocols on Emergency Newborn Care have been adapted from “the Essential
Newborn Care 1996 WHO/FRH/MSM/96.13 and”; “Management of newborn problems: a
Guide for Doctors Nurses and Midwives”, a WHO/UNFPA/UNICEF/World Bank publication
of the integrated Management of Pregnancy and Child birth (IMPAC) series and “MotherBaby Package*”: WHO/FHE/MSM/94.II/ “ as adapted by Government of Tamil Nadu’s Directorate of Reproductive & Child Health and supported by UNICEF India Chennai Field Office.
Ref. WHO / UNFPA / UNICEF / WORLD BANK
1. Implementing Safe Motherhood in Countries Practical Guide – WHO / FHE / MSM /
94.11.
2. Management of Newborn Problems: A Guide for Midwives and Doctors – a WHO
publication of the Integrated Management of Pregnancy and Childbirth (IMPAC)
series. 2003.
3. The Essential Newborn Care 1996 WHO / FRH / MSM / 96.13.
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